Severe osteoarthritis of the knee, also known as DJD or Degenerative Joint Disease

What Is Osteoarthritis?
Osteoarthritis refers to any condition of a joint where either through trauma, inflammation, or wear and tear, the joint wears out and the cartilage is lost, leaving both bones on each side of the joint free to rub together, which is where the pain of arthritis comes from.

What About Osteoarthritis Of The Knee?
In the case of the knee, the loss of cartilage usually begins with an injury or with a torn or lost meniscus sometime in the patient’s earlier years, but not always. Some patient can get arthritis of the knee just through wear and tear or through such conditions as rheumatoid arthritis, where for whatever reasons the cartilage on the end of the femur and the top of the tibia wear away such that the patient has pain in the knee with each step and eventually as it gets bad enough even when the patient is resting.

Common symptoms of endstage osteoarthritis of the knee are basically pain, oftentimes swelling, sometimes catching or locking of the knee, and in many cases deformity of the knee. Many patients whose arthritis progresses significantly enough will notice a severe bowed leg or a severe knock knee, depending on which part of the knee, the inside or medial compartment, or the outside or lateral compartment, that is involved.

How Can This Condition Be Treated?
This condition can be treated a number of ways, starting out with anti-inflammatory drugs, or so-called NSAIDS, which are the common arthritis medicines such as Aleve, ibuprofen, Celebrex, Indocin, Naprosyn, Advil, Mobic, Relafen, etc.

The second line of treatment involves injection therapy, either with something such as cortisone, which is an older drug and has a shorter efficacy, or, #2, a different type of injection can be tried, so-called viscosupplementation. There are about five different products on the market, and basically viscosupplementation is a way of injecting a substance called hyaluronic acid into the knee in order to improve the lubrication and thereby decrease the pain of arthritis in the knee. Hyaluronic acid is a normally-occurring knee fluid component. As a person gets arthritis, he stops producing hyaluronic acid in the normal amounts. In viscosupplementation therapy, hyaluronic acid is injected once a week for three to five weeks into the patient’s knee and over that period of time the patient begins to notice pain relief and usually increased motion if this is going to be effective. Viscosupplementation is effective in about 75% of patients with severe arthritis.

The third line of treatment involves surgery. Sometimes if patients have moderate or mild arthritis and have a torn cartilage, such as a torn meniscus, in their knee, arthroscopic surgery can be an effective means of treating this condition, though the effects of it are somewhat less predictable and may only last at the most a year, in which case the patient’s arthritis might progress requiring them to have more definitive treatment.

The fourth and most definitive line of treatment for endstage osteoarthritis of the knee is knee replacement surgery. In this operation, the arthritic surfaces of the knee are removed. In other words, the very end of the femur is removed and shaped in such a way to allow a metal cap to be placed on the end of the femur. Likewise, the top of the tibia is also removed and a plate is placed on the top of the tibia, which allows the tibia to be resurfaced, and in between these two metal components are placed a polyethylene bearing surface. This surface then becomes the bearing surface of the new knee. There is also a cap placed on the back, or posterior side, of the kneecap so that there is no rubbing of the arthritic kneecap onto the femur, which can also be a source of pain. So, thereby a total knee replacement is when all the arthritic surfaces of the knees are replaced.

What About A Partial Knee Replacement?
A partial knee replacement is appropriate in certain patients whose bone-on-bone arthritis is isolated to one compartment only in their knee, usually the medial compartment or the compartment on the inside of the knee. Likewise, the end of the femur on the medial side and the medial side of the tibia are the only parts of the knee replaced and the rest of the knee is left intact. This is truly minimally invasive knee replacement surgery.

The typical rehabilitation process following knee replacement surgery is fairly extensive. It generally requires a minimum of six weeks of physical therapy, the first three days of which are done in the hospital. The patient then either goes home on the third day and has a therapist come to the house, or maybe spends a week in a rehab unit in a hospital until he or she feels comfortable enough to go home. The best therapy occurs once the patient feels good enough to go to an outpatient physical therapy center, where he can work with a therapist in a physical therapy department using the equipment and exercise techniques available more uniquely in these centers.

How Long Does It Take Until I Am Completely Better?
It can take as little as three months or as long as six months. Knee replacement surgery is a big undertaking. It is a difficult rehabilitation process, but if you are like most people, specifically 93% of people, at the end of your rehabilitation process, you will be rewarded with a good-to-excellent result and will be absolutely certain that knee replacement surgery was the right treatment for your knee.

What About Minimally-Invasive Surgery?
Be careful, minimally invasive surgery is a somewhat over-marketed and underdeveloped technique. The partial knee replacement noted above is easily done through a minimally-invasive technique. However, the total knee replacement still is most consistently done with best results through a standard technique. Certainly the incisions are smaller than they used to be years ago with what is now considered the standard technique, but with minimally-invasive total knee replacements, there have been a myriad of complications and the results are still lacking long-term results.

What Can I Expect If I Have Severe Osteoarthritis Of The Knee And I Do Not Treat It?
Pain. Some knee arthritis will go on to fairly significantly deformity where the knee will become so bowed or so knock-kneed that you will have more and more difficulty walking. However, it is rare that arthritis gets to the point that you would not be able to walk, although in certain severe cases that could be possible.

What is the Patella?
The patella (kneecap) is the bone on the front of the knee which is attached to the quadriceps (thigh musculature) and enables knee extension (straightening out of the knee) to occur at a biomechanical advantage. It also protects the front part of the knee.

What are common complaints with kneecap pain?
When the knee is “straight”, the kneecap has very little pressure on it. When the knee is bent, this increases pressure on the kneecap. For this reason, people with kneecap problems often complain of stiffness or ache when sitting in a movie, theater, on a long car ride, going up or down stairs, or squatting and kneeling. Catching or clicking may also accompany the other symptoms.

What is chondromalacia?
Chondro means cartilage; malacia means softening. This relates to the pathologic condition of softening of the undersurface of the patella, producing kneecap symptoms as described above. Intact cartilage is a protective covering of the bone. When the cartilage is damaged or work away, pain can occur.

How does one get chondromalacia?
This can be developmental, as a result of malalignment (excess pressure is exerted on the patella bone surface from rubbing against the prominence of the femur), or can be a result of direct trauma to the surface of the knee (e.g., an auto accident in which the front part of the knee hits the dashboard).

What is a “tracking” problem of the patella? What is a subluxing or dislocating patella?
The patella moves in a groove or valley of the femur, and in certain cases it “slips” out of the groove. This may be a partial “slippage” termed a subluxation, or a complete dislocation, where the kneecap comes entirely out of the groove laterally (to the outside).

What tests are used to evaluate kneecap problems?
X-rays taken in an oblique plain demonstrate exactly where the patella sits in relation to the femoral trochlear groove. Patellofemoral MRIs can often show exactly how the patella “tracks” in various stages of flexion and extension.

What treatment is available for patellar disorders?
Since the kneecap is often inflamed, non-steroidal anti-inflammatories can be used for a week or two and ice is often prescribed. Strengthening exercises directed at the quadriceps or anterior thigh musculature tend to help the kneecap “track” more physiologically. These can either be done in therapy or at home.

For a true “tracking” problem, a patellar brace may help to keep the kneecap in the center of the femoral groove. McConnell taping, a special tape applied onto the skin, which pulls the kneecap over to the center, is now available. Strengthening exercises can be done with this in place to “retrain” the muscles that affect the patella.

Will I need surgery for my problem?
In over 85% of cases of patellofemoral problems, the treatment is non-surgical, as noted previously. In a small percentage, surgery is required to improve the situation and is either directed at arthroscopically smoothing out the irregular surface of the kneecap, or attempts to “realign” the kneecap so it tracks better in the femoral trochlear groove to decrease pain from excess pressure and “stabilize” the patella to prevent subluxation or dislocation.

If I have any further questions, who can I call?
Please feel free to call Western Orthopaedics at Local:303-321-1333 and ask for a referral to one of the knee specialist. One of the physicians will be happy to answer your questions and evaluate your knee in the clinic.

What exactly is the “meniscus”?
Between the femur and the tibia there are two “cushions” made of fibrocartilage, termed menisci. There is a medical laberal meniscus. These act as cushions for the ends of the bone and protect the surface coating of hyaline cartilage on the ends of the bones.

How does one tear a meniscus?
In younger patients, this results from a flexion (bending) rotation injury where the femur and tibia come together to “pinch” either the medial or lateral meniscus, resulting in a sharp tearing sensation with some swelling. This type of injury is often due to a sporting activity.

In some older individuals, the meniscus can tear gradually as opposed to an acute athletic injury, and one can then gradually have increasing pain and difficulty of either the inside (medial) or the outside (lateral) portion of the knee.

If I have a torn meniscus, what will my symptoms be?
This primarily depends upon the size of the meniscal tear. If a large tear is present, this may actually move in the joint and produce “locking” of the joint, so that one is unable to fully straighten the knee.

If the tear is smaller, then one may simply have annoying slicking, catching pain with twisting movements, or increased pain on attempted squatting maneuvers.

How do I tell whether my meniscus is torn?
Menisci are not seen on plain x-rays, and therefore, MRI of the knee is often indicated.

What is the treatment for torn cartilage?
If a tear is seen on MRI and if the tear is producing mechanical symptoms in the knee (e.g., locking, clicking, swelling, catching, increased pain with twisting movements, inability to play sports), one often must consider arthroscopic treatment of the tear.

Arthroscopic treatment of the tear usually involves either resecting the unstable portion of the tear or repairing the tear.

Why can’t all meniscal tears be repaired?
The central portion of the meniscus does not have adequate blood supply, therefore unless the tear is very peripheral – away from the center of the joint – the meniscus will not heal even if it is sutured.

Is the recovery after meniscal repair different than after meniscal resection?
Yes. With meniscal repair, it takes four to six months for the meniscus to heal adequately to resume sports; if a meniscal is “resected”, on is usually able to play cutting sports in four to six weeks.